Managing STEMIs without a Catheterization Lab: A Simulated Scenario to Improve Emergency Clinician Recognition and Execution of Thrombolysis in the Setting of Rural STEMI Management

Audience The targeted audience for this simulation is Emergency Medicine (EM) residents. Medical students, advanced practice providers, and staff physicians could all also find educational merit in this scenario. Background Cardiovascular disease is the leading cause of death in the United States according to the CDC.1 Coronary artery disease caused 375,000 deaths 2021 alone, and about 5% of all adult patients have a prior history of coronary artery disease.2 Furthermore, chest pain itself is a common chief complaint encountered in the ED, with nearly 8 million visits annually occurring throughout the United States, with 10–20% of those patients ultimately being diagnosed with an acute coronary syndrome3, including ST-elevation myocardial infarction (STEMI). Given this, it is essential that EM residents are well prepared to care for all patients presenting with chest pain, regardless of the acute care or emergency setting. Throughout their training, most EM residents typically learn and evaluate patients at a large tertiary or quaternary medical center with 24-hour catheterization laboratory availability. For patients presenting with electrocardiogram (EKG) findings consistent with STEMI, the standard of care is for the patient to undergo cardiac catheterization and stent placement within 90 minutes of arrival. Unfortunately, only half of patients living in rural areas have a cardiac catheterization-capable facility available to them within a 60-minute driving radius, making it difficult for those patients to undergo cardiac catheterization within the desired time frame.4 These patients remain candidates for thrombolytic therapy, but given infrequent opportunities to learn about and deploy thrombolytic agents during residency training, graduating EM residents may be unfamiliar with indications, dosing, and contraindications before they begin practice. Furthermore, the recent EM workforce data suggests that although there may be an oversupply of 8,000 emergency physicians by 2030, robust practice opportunities for emergency physicians remain in rural settings.5 Although historically EM graduates have not selected rural areas for practice, with only approximately 8% of emergency physicians practicing in rural areas,6 it is likely that given the opportunities present and perceived saturation in many non-rural settings, more EM graduates will pursue practice in a rural setting. With these changing practice dynamics in mind, this simulation provides the opportunity for residents and medical students to experience the management of a STEMI in the rural setting, with a focus upon the indications, contraindications, dosing, and disposition of a patient receiving thrombolytics. Educational Objectives By the end of this simulation, learners will be able to: Diagnose ST elevation myocardial infarction accurately and initiate thrombolysis in the rural setting without timely access to cardiac catheterization. Engage the simulated patient in a shared decision-making conversation, clearly outlying the benefits and risks of thrombolysis. Identify the indications and contraindications for thrombolysis in ST elevation myocardial infarction. Arrange for transfer to a tertiary care center following completion of thrombolysis. Educational Methods This scenario is a simulated encounter in a rural emergency department setting requiring the diagnosis of a STEMI, a discussion with the patient regarding the risks and benefits of thrombolysis prior to administration, administration of thrombolysis, and transfer of patient to a higher level of care. Research Methods The educational content of this simulation as a teaching instrument was evaluated by the learner utilizing an internally developed survey after case completion. This survey was reviewed for precision of language and assessment of learning objectives by our simulation faculty and other members of our West Virginia University Emergency Medicine Department of Medical Education. The learner was asked to specify any prior experience with rural STEMI management as well as quantify via a five-point Likert Scale, where 1 = very uncomfortable and 5 = very comfortable, their level of comfort with thrombolysis before and after the scenario as well as their comfort with having a shared decision-making conversation with patients with regards to thrombolysis. Learners were also asked to rank the helpfulness of this simulation in preparing them for administering thrombolytics for STEMI in a rural setting on a five-point Likert scale, where 1 = not helpful and 5 =very helpful. An open response section was also provided to allow learners the opportunity to comment directly on any aspect of the simulation. Results Data was collected anonymously from 16 PGY1-3 resident learners via surveys with a 100% response rate. Overall, the feedback received regarding the simulation was positive. There was a low average comfort level with administering thrombolytics and having a shared decision-making conversation regarding administering thrombolytics. There was a high average rating of the helpfulness of this simulation in preparing residents for this conversation as well as managing STEMIs in a rural setting. Subjective comments regarding the simulation were universally positive. Discussion The management of STEMI in the rural emergency department differs significantly from the environment in which many EM residents train. As a leading cause of death in the United States, STEMI management is a vital component of EM resident education. Although the concept of thrombolysis in the rural setting is discussed, the opportunity for real-world experience in its execution is often limited despite many graduates ultimately working in rural emergency departments. This simulation sought to provide a realistic patient encounter to promote familiarity and comfort in the identification, patient discussion and execution of thrombolysis in the treatment of a STEMI. The educational content was shown to be effective via learner survey completion.

Throughout their training, most EM residents typically learn and evaluate patients at a large tertiary or quaternary medical center with 24-hour catheterization laboratory availability.For patients presenting with electrocardiogram (EKG) findings consistent with STEMI, the standard of care is for the patient to undergo cardiac catheterization and stent placement within 90 minutes of arrival.Unfortunately, only half of patients living in rural areas have a cardiac catheterization-capable facility available to them within a 60-minute driving radius, making it difficult for those patients to undergo cardiac catheterization within the desired time frame. 4These patients remain candidates for thrombolytic therapy, but given infrequent opportunities to learn about and deploy thrombolytic agents during residency training, graduating EM residents may be unfamiliar with indications, dosing, and contraindications before they begin practice.Furthermore, the recent EM workforce data suggests that although there may be an oversupply of 8,000 emergency physicians by 2030, robust practice opportunities for emergency physicians remain in rural settings. 5Although historically EM graduates have not selected rural areas for practice, with only approximately 8% of emergency physicians practicing in rural areas, 6 it is likely that given the opportunities present and perceived saturation in many non-rural settings, more EM graduates will pursue practice in a rural setting.With these changing practice dynamics in mind, this simulation provides the opportunity for residents and medical students to experience the management of a STEMI in the rural setting, with a focus upon the indications, contraindications, dosing, and disposition of a patient receiving thrombolytics.
Educational Objectives: By the end of this simulation, learners will be able to: 1. Diagnose ST elevation myocardial infarction accurately and initiate thrombolysis in the rural setting without timely access to cardiac catheterization.2. Engage the simulated patient in a shared decision-making conversation, clearly outlying the benefits and risks of thrombolysis.3. Identify the indications and contraindications for thrombolysis in ST elevation myocardial infarction.4. Arrange for transfer to a tertiary care center following completion of thrombolysis.
Educational Methods: This scenario is a simulated encounter in a rural emergency department setting requiring the diagnosis of a STEMI, a discussion with the patient regarding the risks and benefits of thrombolysis prior to administration, administration of thrombolysis, and transfer of patient to a higher level of care.

Research Methods:
The educational content of this simulation as a teaching instrument was evaluated by the learner utilizing an internally developed survey after case completion.This survey was reviewed for precision of language and assessment of learning objectives by our simulation faculty and other members of our West Virginia University Emergency Medicine Department of Medical Education.The learner was asked to specify any prior experience with rural STEMI management as well as quantify via a five-point Likert Scale, where 1 = very uncomfortable and 5 = very comfortable, their level of comfort with thrombolysis before and after the scenario as well as their comfort with having a shared decision-making conversation with patients with regards to thrombolysis.Learners were also asked to rank the helpfulness of this simulation in preparing them for administering thrombolytics for STEMI in a rural setting on a five-point Likert scale, where 1 = not helpful and 5 =very helpful.An open response section was also provided to allow learners the opportunity to comment directly on any aspect of the simulation.
Results: Data was collected anonymously from 16 PGY1-3 resident learners via surveys with a 100% response rate.Overall, the feedback received regarding the simulation was positive.There was a low average comfort level with administering thrombolytics and having a shared decision-making conversation regarding administering thrombolytics.There was a high average rating of the helpfulness of this simulation in preparing residents for this conversation as well as managing STEMIs in a rural setting.Subjective comments regarding the simulation were universally positive.Discussion: The management of STEMI in the rural emergency department differs significantly from the environment in which many EM residents train.As a leading cause of death in the United States, STEMI management is a vital component of EM resident education.Although the concept of thrombolysis in the rural setting is discussed, the opportunity for real-world experience in its execution is often limited despite many graduates ultimately working in rural emergency departments.This simulation sought to provide a realistic patient encounter to promote familiarity and comfort in the identification, patient discussion and execution of thrombolysis in the treatment of a STEMI.The educational content was shown to be effective via learner survey completion.
Topics: Thrombolysis, ST-elevation myocardial infarction, STEMI, myocardial infarction, MI, rural, heart attack, simulation.5 = very comfortable, learners reported low comfort levels with administering thrombolytics to treat STEMIs prior to completing the simulation, with an average of 2.4 and a standard deviation of 0.9.Comfortability with shared decision making regarding thrombolytic administration was evaluated with the same Likert scale, and learner comfort was higher with thrombolytic administration, with an average of 3.3 and a standard deviation of 1.2.Learners were asked to rank the helpfulness of this simulation in preparing them for administering thrombolytics for STEMI in a rural setting on a Likert scale where 1 = not helpful and 5 =very helpful.Overall, learners found the simulation very helpful with an average score of 4.6 with a standard deviation of 0.7.Finally, with regards to how the simulation helped residents feel comfortable with having a shared decision-making conversation centered on thrombolytic administration, residents felt that the simulated scenario was very helpful overall with a post-simulation score of 4.6 with a standard deviation of 0.6.Comments in the open response section were universally positive.Below are some sampled comments from learners: "This was an excellent simulation.We are often involved in care of stroke patients who receive TPA, but I have never been the one to have the informed consent conversation with families or patients.Therefore, I did not feel comfortable with the correct way to have the conversation and the correct risk and benefit information to provide to them.The learner is first challenged to correctly identify the patient as having an acute STEMI.The learner must then assess the capabilities of their institution before correctly articulating thrombolysis as the indicated treatment prior to transport.A detailed risks/benefits discussion must then be had with the patient before initiating treatment.Failure to identify the STEMI or lack of timely initiation of thrombolysis will result in acute decompensation of the patient.The learner will have successfully completed the scenario when the patient's clinical status has improved, and the patient is appropriately designated for transportation to higher level of care and cardiac catheterization.Post-case debriefing should highlight the objectives of the case and allow the learner to ask questions while the teaching points of the case are discussed.

Equipment or Props Needed:
High fidelity manikin capable of voice and vital sign findings to represent the STEMI patient.Ready-made printouts of lab findings, x-rays, and vital sign changes in response to delay of treatment enhances the simulation.A standardized patient could also be implemented.

Actors Needed:
A confederate playing the role of the nurse will be needed to facilitate interactions and help advance the case.A confederate will also be needed to voice the manikin and input vital sign changes as necessary into the manikin software.The case could be deployed utilizing a standardized patient in lieu of a manikin, in which case a confederate would be needed to play the role of the STEMI patient.

Background and brief information:
The learner is asked to assume the role of an attending physician in a resource-limited, rural ED where a middle-aged man presents with chest pain and electrocardiographic evidence of a STEMI.If the STEMI is not recognized and thrombolysis is not initiated in a timely manner, the patient will decompensate and require emergent intervention.

Initial presentation:
Nursing introduces the patient and the history of present illness (HPI) is presented by the patient.The patient is a 58-year-old man complaining of a three-day history of intermittent chest pain which acutely worsened today while eating and has been constant for the past three hours.The discomfort is described as "an elephant sitting on my chest" and associated with dyspnea and nausea.Of note, the patient indicates that he was in a low energy motor vehicle collision without airbag deployment one week ago and has been diffusely sore since that time but did not seek medical intervention.The patient indicates that he does not regularly visit a physician and is on no medications at the present time.He is a half pack per day smoker and does not drink or use illicit drugs.The patient will look uncomfortable upon exam, but there are no other pertinent exam findings.

How the scene unfolds:
The learner should quickly diagnose the patient with an inferior STEMI via a promptly obtained EKG (stimulus 1).Lab work, if obtained, will demonstrate a significantly elevated troponin (stimulus 5).Chest x-ray will be unremarkable (stimulus 4).Failure to promptly recognize and treat the STEMI via indicated thrombolysis will result in patient decompensation with worsened chest discomfort, hypotension, worsening tachycardia and oxygen saturation.The learner(s) must have a shared decision-making conversation with the patient regarding thrombolysis during which the patient will express concerns regarding his recent motor vehicle collision.Shared decision making should result in the decision to pursue thrombolysis.Post lysis, the patient will express improving symptoms and vital signs will stabilize.The patient should then be arranged for transfer to a percutaneous coronary intervention (PCI) capable facility.
For more advanced learners, several additional complications could be added.Inclement weather could impede patient transport.The patient could suffer a post-lytic induced dysrhythmia, such as ventricular tachycardia, requiring additional actions like cardioversion.
The patient could suffer from persistent hypotension from the inferior MI and require additional resuscitation.

Rural STEMI Management
Thrombolysis of STEMI patients is an important tool of the emergency clinician.As emergency physicians may be faced with a need to choose rural practice sites, 6 they will need to confidently administer thrombolysis to appropriate STEMI patients. 7Upon completion of this scenario, the learner should be more familiar and comfortable in the indication, discussion, execution, and disposition of the rural STEMI patient requiring lysis.Learners should finish the case and the debriefing with confidence in discussing the mortality benefits of lytic therapy in treating STEMI 7 against the low (0.5-1% risk of intracranial hemorrhage) risks associated with lytic administration in the absence of contraindication.Other debriefing points: If the learners failed to identify the STEMI in a timely manner, spend some time exploring the frame that led them to view the ECG incorrectly.Ensure adequate discussion of the indications and contraindications to thrombolysis, with specific focus upon how the low mechanism MVC several days prior to does not represent a contraindication to thrombolysis.For more junior learners, the case can be used to facilitate a discussion regarding the frameworks underlying the evaluation of undifferentiated chest pain patients in the ED.Explain the appropriate workup of all chest pain patients and the need for timely ECG interpretation.If the learner allows the patient's concerns of the low mechanism MVC multiple days ago to interfere with indicated thrombolysis of an acute STEMI, explore barriers the learner may have when executing an appropriate risks/benefits discussion.This discussion should center on the demonstrated mortality benefit of thrombolytics in combination with PCI in patients with acute MI remote from a PCI capable center. 8The learner should have ready recall of the 0.5-1% risk of intracranial hemorrhage as the primary risk in this shared decision-

8
Absolute contraindications to thrombolytic treatment are 9 : • Recent intracranial hemorrhage • Known cerebrovascular lesion, like arteriovenous malformation (AVM), or known intracranial mass • Ischemic stroke within three months • Possible aortic dissection • Active bleeding • Significant head injury or facial trauma within three months • Recent intracranial or spinal surgery • Severe uncontrolled hypertension.

Time for case: 10-15 minutes Time for debriefing: 10-20 minutes Recommended Number of Learners per Instructor:
Schoenborn S, Steratore AF, Hoffman A, Marshall TC, Shaver EB, Kiefer CS.Managing STEMIs without a Catheterization Lab: A Simulated Scenario to Improve Emergency Clinician Recognition and Execution of Thrombolysis in the Setting of Rural STEMI Management.JETem 2024.9(2):S55-76.https://doi.org/10.21980/J8K933 Managing STEMIs without a Catheterization Lab: A Simulated Scenario to Improve Emergency Clinician Recognition and Execution of Thrombolysis in the Setting of Rural STEMI Management Great work!" "Very helpful to have community setting/low resource simulation.""Ithought this SIM was good in that 1.It made you need to filter out extraneous information.2.It made you "pull the trigger" on ordering thrombolytics to a patient.3.We reviewed shared decision-making discussions/importance!" INSTRUCTOR MATERIALS Schoenborn S, Steratore AF, Hoffman A, Marshall TC, Shaver EB, Kiefer CS.Managing STEMIs without a Catheterization Lab: A Simulated Scenario to Improve Emergency Clinician Recognition and Execution of Thrombolysis in the Setting of Rural STEMI Management.JETem 2024.9(2):S55-76.https://doi.org/10.21980/J8K933CaseTitle: